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case report | DOI: https://doi.org/10.31579/2690-4861/580
*Corresponding Author: Alada Muslimat Ajibola, Asokoro Distric Hospital/Nile University of Nigeria.
Citation: Ahmed B Abougamil, Ahmed Raslan, Eleni Maratos, Nick W Thomas and Sinan Barazi, (2025), Femoral Fracture During Neonatal Circumcision: An Unusual and Avoidable Complication, International Journal of Clinical Case Reports and Reviews, 25(2); DOI:10.31579/2690-4861/580
Copyright: © 2025, Alada Muslimat Ajibola. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 11 March 2025 | Accepted: 28 March 2025 | Published: 11 April 2025
Keywords: femur; femoral fracture; neonatal circumcision; circumcision complication
Neonatal circumcision is a common surgical procedure. Although complications occur, femoral fracture is rarely reported. A 10-day old boy presented with swelling of the right thigh and irritability four hours after circumcision. He was said to have been forcefully restrained at both thighs during the procedure because anaesthesia was not given. Clinical and radiologic evaluation showed a fracture of right femur. The fracture was treated by Gallows traction along with care of the circumcision wound. He did well and was discharged home after 16 days. Neonatal femoral fractures are rare and usually due to birth injury. Femoral fracture occurring during circumcision is rare and avoidable. Training and retraining of personnel involved in circumcision regarding the techniques of the procedure, appropriate analgesia and safety points are crucial to avoiding such complication.
Circumcision is a common practice, often for cultural and religion reasons, [1,2] and sometimes for established medical reasons. [3] It is the most common surgical procedure performed on male neonates in several countries. [3]
Complications of circumcision, usual and unusual have been reported. [4,5] This is report of an unusual complication remote from the site of surgical procedure.
A 10 days old male neonate was brought by the parents on account of swelling of the leftt thigh and irritability which started 4 hours prior to presentation. Symptoms were noticed following circumcision done by a nurse in another hospital. Circumcision was carried out with the baby in supine position, without any form of anaesthesia. He was said to have been forcibly restrained at both thighs during the procedure by a relation. There was no history of birth trauma or deformity of the thigh from birth. On presentation, he was irritable, the right thigh was swollen with anterior angulation in the proximal part. Phallus showed a fresh circumcision wound. X-rays (Figure 1) showed a transverse, displaced fracture of the left femur, no evidence of underlying bone disease. The femoral fracture was treated with Gallow’s Traction and the circumcision wound was cleaned and dressed. He did well and was discharged after 16days.
Figure 1: showing X ray of left femoral fracture
Femur fractures in neonates are relatively uncommon and are usually due to birth trauma.[6][10][11] Femur fracture following forceful restraint during circumcision is rare. In this particular case scenario, three fundamental aspects of the procedure contributed to this rare complication.
The first is that the circumcision was performed by health personnel without requisite structured training in surgery or the procedure; hence appreciation of safety points of the procedure is neglected resulting in this grave complication. Even though complications can occur in appropriately trained hands, there have been several reports of grave complications occurring when circumcision is done by untrained personnel. [2,4,5] There is a need for training not only in the technical aspect of the procedure but also how to ensure safety of the patient.
Positioning and restraint of the patient is crucial to good surgical exposure.[7] In this patient a relative provided forceful restraint at the thigh with flexion, abduction and full external rotation of the hip, thereby pinning the baby down. There was resistance by the baby and this led to further application of force by the relative. This was done without appropriate instruction and regard to the fragile nature of the baby’s bone. This disproportionate restraint led to the fracture of the femur.
Routine neonatal circumcision is a painful clinical procedure that requires intra-op and post-op analgesia. [2,8,9] However, most routine neonatal circumcisions are unfortunately still done without anaesthesia and where anaesthesia is given it is inappropriate or too insufficient. [9] In this patient, effective anaesthesia would give a calm baby with significant less resistant making positioning easier and forceful restraint unnecessary. The femoral fracture would have been avoided.
There is a need for circumcision to be performed by appropriately trained person with attention to good analgesia and patient safety.
Conflict of interest
The authors declare no conflict of interest in the writing of this paper.
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